Alert for Directors of Nursing

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Establishing, Implementing, and Continuing an Effective
Continence Program in a Long-term Care Facility

Urinary incontinence (UI) affects more than half of all
Americans in home or long-term care settings. However, studies
show that appropriate treatment can help most people who suffer
from UI to regain some control. Your role as Director of Nursing
(DON) places you in a unique position. A program of diagnosis and
treatment specifically for incontinence can improve the condition
or cure many residents in your facility who have UI.

The key to the success of this program is the active
participation of certified nursing assistants (CNAs) in
implementing a continence care plan. To assist you in educating
the caregivers in your charge, the Agency for Health Care Policy
and Research, American Medical Directors Association, and
American Health Care Association have developed a short,
plain-language booklet entitled Helping
People With Incontinence.

In situations where continence programs have been implemented,
the results prove their effectiveness. For example, a
Chattanooga, TN, nursing facility using the 1992 AHCPR UI
guideline was successful in reducing the number of incontinent
patients by 65 percent and more than doubling the number of
normally dry residents over a 14-month period. This included six
residents who had been considered untreatable.

The essential elements of a continence program are
education, motivation, and followup. It requires your
commitment to:

Initiate and maintain a comprehensive, science-based
approach to diagnosing and treating UI.

Provide ongoing education and motivation to CNAs in your
charge.

Develop and foster a team approach, encouraging CNAs,
licensed nurses, and attending physicians to participate
actively in the continence program.

Continually followup by providing feedback and responding
to the changing needs of caregivers who implement the
program.

Education

Evaluating UI

In order to get started, your team will need to assess each
resident carefully to determine the type of UI he or she might
have. This assessment should include:

A focused medical, neurologic, and genitourinary history
that includes an assessment of risk factors, a review of
medications, and a detailed exploration of UI and
associated symptoms.

The completion of bladder records to determine the
frequency, timing, and amount of voids; number of
incontinent episodes; activities associated with UI; and
fluid intake.

A mental status evaluation, including assessment of
cognition and of the ability to self-toilet.

A functional assessment of manual dexterity and mobility.

An environmental assessment (e.g., access and distance to
toilets and toilet substitutes; whether the chair/bed
allows ease when rising).

A physical examination (by a primary care provider),
including any necessary supplementary assessments, such
as measurement of post-void residual volume.

Identifying UI

Some residents' UI is transient, caused by a reversible
condition or cause, such as urinary tract infection, stool
impaction, or the use of caffeine or certain medications. In some
cases, once the condition or cause is resolved, so is the
resident's UI.

But in many other residents with UI—especially older and
frail residents—the factors causing UI are multiple and
complex. For these residents, a more comprehensive approach to
treatment is required. Such an approach must be tailored to the
resident's type of UI. UI can be classified as:

Urge incontinence—involuntary loss of urine associated
with a strong sensation of urgency, often on the way to the
bathroom.

Stress incontinence—loss of urine during coughing,
sneezing, laughing, or other activities that increase bladder
compression.

Mixed incontinence—combination of urge and stress
incontinence.

Overflow incontinence—leakage of urine associated with
overdistension of the bladder.

Functional incontinence—physical or cognitive limitation
that may impair toileting.

Unconscious or reflex incontinence—loss of urine that
occurs without warning or sensory awareness in residents such as
paraplegics and in others without overt neurologic dysfunction.

Treating UI

There are three major categories of treatment for UI:

Behavioral—noninvasive interventions that involve the
patient and caregiver, including pelvic exercises, toileting
schedules, and bladder training.

Pharmacologic—medications to control abnormalities in
bladder/sphincter function.

Surgical—to repair or treat specific anatomical problems.

Other measures and supportive devices in the management of UI
include use of catheters, external collection systems, pelvic
organ support devices, and protective pads and garments. These
treatment options are explained more fully in the quick reference
guide.

As a general rule, the first treatment choice should be the
least invasive with the fewest potential adverse complications
that is appropriate for the individual resident. Behavioral
techniques meet these criteria for many forms of UI, and these
will be the main techniques used by the CNAs. But the resident's
or family's wishes always must be respected.

Although many persons can benefit from behavioral,
pharmacologic, or surgical interventions for UI, many others
cannot. Typically, these persons have cognitive or physical
impairments that prevent them from learning or performing
behavioral methods. In addition, these individuals often cannot
tolerate or would not benefit from pharmacologic or surgical
options.

The care plan for persons with chronic UI should include
attention to toileting schedules, fluid and dietary intake,
strategies to decrease urine loss at night, use of the most
absorbent and skin-friendly protective garments, and prevention
and early treatment of skin breakdown. Specific recommendations
for the management of chronic UI are provided in the quick
reference guide. Instructions for CNAs, including specific
information on toileting options, are contained in the caregiver
guide, Helping
People With Incontinence.

Before a resident is classified as suffering from chronic
intractable UI, the most appropriate intervention should be
attempted. Any care plan for these residents must involve careful
education of the CNA as to the problem and intent of the
treatment option. You should review the caregiver guide with the
CNAs to ensure their understanding of their role in the treatment
plan.

Motivation

The key to an effective continence program is teamwork. Your
leadership is integral to its success. The team needs
reinforcement of the basic principles of behavioral therapy and
motivation to continue with the program. Those involved need to
know that they are essential members of an important team that
includes themselves, you, the residents, and the attending
physicians. They also need your support to help them implement
whatever treatment plan is chosen.

Followup

Maintaining an effective continence program requires:

Continual education of CNAs and support staff to ensure
that they understand their job.

Ongoing evaluation of residents to assess the benefits of
the care plan, utilizing bladder records and feedback
from the team.

Adapting the care plan to meet the changing needs of the
resident.

Implementation

As the DON, you can devise a plan that will maintain or
improve the continence of the residents in your facility. The
CNAs are critical to the success of that plan; you need to train
them carefully and then reinforce their understanding of the
behavioral treatments for UI.

More attention is needed to provide the best care for the
chronically incontinent, but there are treatments that are
effective in improving their continence. This clinical practice
guideline, with its various versions, was created to help you
find the best methods, no matter the level of your residents'
continence.

Implementation of the basic principles of the guideline has
shown that significant improvements can be made in even the most
difficult cases. You can realize that same success. Tell us about
your successes by sending an E-mail message to: https://info.ahrq.gov

AHCPR Publication No. 96-0063
Current as of August 1996

The information on this page is archived and provided for reference purposes only.